A nurse on a postpartum unit is caring for a group of clients. Which of the following clients is the nurse’s priority?

A client who is 2 days postpartum and whose fundus is 2 to 4 cm below the umbilicus.

A client who is 3 days postpartum and has not had a bowel movement since prior to admission.

A client who is 4 days postpartum and has lochia serosa.

A client who is 1 day postpartum and has not voided in 8 hr.

Answer and Explanation

The Correct Answer is D

A client who is 1 day postpartum and has not voided in 8 hr. This client is at risk of urinary retention, bladder distension, and infection due to the effects of epidural anesthesia, perineal trauma, and fluid shifts after delivery. The nurse should assess the client’s bladder and catheterize if necessary.

Choice A is wrong because a client who is 2 days postpartum and whose fundus is 2 to 4 cm below the umbilicus is showing a normal finding.

The fundus should descend about 1 to 2 cm per day after delivery and be nonpalpable by day 10.

Choice B is wrong because a client who is 3 days postpartum and has not had a bowel movement since prior to admission is not uncommon.

Constipation is a common problem after delivery due to decreased peristalsis, dehydration, and fear of pain.

The nurse should encourage fluid intake, fiber intake, and early ambulation to promote bowel function.

Choice C is wrong because a client who is 4 days postpartum and has lochia serosa is also showing a normal finding.

Lochia serosa is the pinkish-brown discharge that occurs from day 4 to 10 after delivery.

It consists of old blood, serum, leukocytes, and tissue debris.

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Correct Answer is B

Explanation

Justice is the ethical principle of treating the patient fairly and equally among staff when making assignments. The charge nurse is upholding this principle by ensuring that the workload is distributed evenly and that no staff member is overburdened or underutilized.

Choice A is wrong because Veracity is wrong because veracity is the ethical principle of telling the truth to the patient.

This principle is not relevant to the scenario of making assignments.

Choice C is wrong because Autonomy is wrong because autonomy is the ethical principle of respecting the patient’s right to make their own healthcare decisions.

This principle is not relevant to the scenario of making assignments.

Choice D is wrong because Fidelity is wrong because fidelity is the ethical principle of keeping promises to the patient.

This principle is not relevant to the scenario of making assignments.

A. Avoid asking the client personal questions. B. Observe the client’s body language during the conversation. C. Maintain eye contact with the interpreter when asking questions. D. Include medical terminology when discussing the client’s condition.

Correct Answer is B

Explanation

Observe the client’s body language during the conversation. This action will help the nurse to assess the client’s nonverbal cues and emotions, which can enhance communication and understanding. The nurse should also determine the client’s understanding several times during the conversation and use lay terms if possible.

Choice A is wrong because avoiding asking the client personal questions can hinder rapport building and prevent the nurse from obtaining important information about the client’s health and needs.

Choice C is wrong because maintaining eye contact with the interpreter when asking questions can show disrespect and disinterest to the client and his family. The nurse should look at the client and his family when asking questions, not at the interpreter.

Choice D is wrong because including medical terminology when discussing the client’s condition can confuse the client and his family and create barriers to communication. The nurse should use simple and clear language that the client and his family can understand.

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A nurse on a postpartum unit is caring for a group of clients. Which of the following clients is the nurse’s priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse at a long-term care facility ensures that the workload is distributed equally among staff when making assignments. Which of the following ethical principles is the nurse upholding?

Correct Answer is B

Explanation

A nurse is using an interpreter to communicate with a client who speaks a different language than the nurse. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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